Pragmatism In Psychiatric Diagnosis

Dr Nassir Ghaemi has written a blog post challenging me to defend pragmatism in psychiatric diagnosis and stating that the problems of DSM 5 are equivalent to, and rooted in, those in DSM IV.

Here is part of Dr Ghaemi's challenge: "A member of the DSM-IV task force told me that the leader of DSM-IV ... said that in addition to their scientific evaluation of the material there, they should keep in mind three overriding principles:

1. To make no changes unless the scientific evidence was extremely strong (ie., DSM conservatism).

2. To make no changes that would lead to radical changes in the document (DSM conservatism again), and

3. To make no changes that would harm insurance reimbursement to clinicians (economics).

Perhaps the former leader of DSM-IV can confirm publicly if these were his instructions."

Dr Ghaemi has my first two instructions to the DSM IV Task Force completely right. No change in the diagnostic system should ever be made unless it is supported by strong science and vetted for its possible risks as well as its hoped for benefits.

His alleged third instruction is inaccurate. When we began work on DSM IV in 1987, I laid out the following hierarchy- DSM IV's clinical purpose came first and was paramount; followed, at considerable distance, by its uses in research, education, forensics; and then, much further back, that we shouldn't be dumb about DSM's impact on administrative decisions (disability, VA benefits, insurance reimbursement, school services etc)- but that these were hard to predict and wouldn't be determining.

Dr Ghaemi ignores the two reasons why pragmatics must necessarily play a large role in making DSM decisions:

•The science is always incomplete and never clear cut. Data doesn't jump up, grab you by the throat, and tell you what to do. The science is always subject to different interpretations.

•DSM has become far too important in people's lives to ignore its practical impact. Seemingly small changes can result in the mislabeling of millions of 'patients' who are then subjected to unnecessary and often harmful treatments, stigma, costs.

Dr Ghaemi goes on: "This means making practical judgments about what is best for the psychiatric profession, first of all, and then for social, economic, or other reasons. We should change criteria, said my colleague explicitly, so that clinicians should be induced to use more or less of some medications (such as antipsychotics, less, versus antidepressants, more) based on the beliefs of the leadership of the DSM task forces about the risks and benefits of those medications."

Dr Ghaemi has it wrong again. The practical judgments must not be based on what is best for psychiatry- rather, they are based on what is likely to be best for potential patients and for the public health. And yes, we should not be introducing poorly tested and overly inclusive new diagnoses (or reducing the thresholds for existing ones) when this will give an opening to the misleading and aggressive drug company marketing that already has one in five Americans taking an often unnecessary psychotropic drug.

Our country has a very real practical problem that Dr Ghaemi seems oblivious to. We are currently over diagnosing and over treating many people who would be better off left alone and shamefully neglecting the really ill who desperately need and can benefit from our help. DSM IV tried (with only partial success) to stem the tide. DSM 5 has opened the floodgates to much more mislabeling and to drug company misleading marketing.

Dr Ghaemi also somehow fails to understand the quite obvious differences in the goals, methods, and values of DSM iV and DSM 5. Their diametrically opposite goals- DSM IV to be safe; DSM 5 to be innovative. Their opposite methods- DSM IV was boringly meticulous; DSM 5 was recklessly disorganized. Their values- DSM IV embraced pragmatism; DSM 5 explicitly renounced it, making the fallacious claim that is decisions were science based.

When we completed DSM IV, I felt we had done a careful and good job. But we failed to predict or prevent subsequent huge increases in the diagnosis of ADD, autism, and adult bipolar disorder. DSM 5 has been oblivious to its practical impact and to the practical risks of harmful unintended consequences.

If anything, our diagnostic system needs shrinking- instead DSM 5 is recklessly expanding the definition of mental disorder and making it. The following problems of DSM 5 are due to utter its lack of pragmatism, not any presumed excess. dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes

Dr. Francis, you may have tiger by the tail. The DSM as final authority, or even serious authority, is under challenge by the Internet.
You say: “The science is always incomplete and never clear cut. Data doesn't jump up, grab you by the throat, and tell you what to do. The science is always subject to different interpretations.”---Although not intended, this is an invitation to postmodernist hegemony--- there is no clear truth so authority decides. The fact is, incomplete science often points in suggestive directions and psychiatrists are only somewhat more qualified than any other intelligent observer to evaluate their validity.
You say. “DSM has become far too important in people's lives to ignore its practical impact. Seemingly small changes can result in the mislabeling of millions of 'patients' who are then subjected to unnecessary and often harmful treatments, stigma, and costs.”---If small changes in the DSM cause patients to be dramatically subject to harmful treatments, then psychiatry is a very suspect profession. It is, but so is all expertise these days.

The Internet is here, and wise patients use it. Psychiatry must empower thinking, as for example Jim Phelps admirably advocates. Without serious caution one may appear to be trying to sustain something a little too close in spirit to a fundamentalist religion than is useful in an information age.

Somewhere Jim Phelps has posted and article on Doctor as Teacher. As Dr. Francis has correctly pointed out, TV ads have contributed in serious ways to over treatment. How much more important for the Doctor be a scholar in order to be a teacher?

The DSM has a role as an ongoing, regularly updated, digestible guide to science. That would be noble aspiration.

Sony leads in multiplatform games sales!) Next it will likely
be crap like Extra PS4 controllers have been bought than Xbox
One; Sony has extra social avid gamers.” These numbers do
not give useful data. Silly Xbox fanboy PS4 owners have so many,
many extra games to pick out from on the PS4 and buy
than you have got over in Xboxville we can't purchase
them all. Funny although that the flag ship video games like Madden and FIFA and NHL all sell
higher over in Sony nation.

Dr. Frances is correct - and hopelessly out of fashion - when he says that "the science is always incomplete and never clear cut. Data doesn't jump up, grab you by the throat, and tell you what to do. The science is always subject to different interpretations." Some years ago he and his co-authors wrote a book, "Differential Therapeutics in Psychiatry: The Art and Science of Treatment Planning," which is as useful today as it was when it was published, largely because the authors show - case by case, diagnosis by diagnosis - why, if your goal is to help your patients, "the science" will only take you so far. Unfortunately, the psychiatry and clinical psychology establishments have for some time been suffering from variant strains of Scientism, a virulent disorder which closes the minds and hardens the hearts of those who allow themselves to become infected, while thousands of dedicated individual clinicians from these and other disciplines have continued to do their best to help patients whose problems rarely, if ever, fit neatly within preconceived categories, regardless of how "scientific" those categories may be.